Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth

What is the issue?

A pregnancy normally lasts between 37 and 40 completed weeks. If the birth takes place earlier than that and the baby is born prematurely, there is a high risk that the baby will have breathing problems and might suffer from other complications. There is also a risk that the premature baby dies, especially if it is born in a facility that does not have advanced care for newborns. Mothers with signs of premature labour or planned for elective preterm birth are commonly injected with steroids, which can help mature the baby's lungs and prevent severe breathing problems once the baby is born.

Why is this important?

In high‐income countries and in hospital settings with advanced care facilities, administration of steroids for mothers who are at risk of giving birth prematurely is standard care. As this is not always the case in low‐income countries, where premature birth is more common compared to other countries, there have been worldwide efforts to increase the use of steroids in these settings. However, as there is usually also a lack of other supportive newborn care and accurate assessment of gestational age in these settings, the benefits and harms of increasing the use of steroids, compared to usual approach of care, need to be evaluated.

What evidence did we find?

We searched for evidence in September 2019 and identified three studies that met our inclusion criteria. All three studies assessed interventions that aimed to promote the use of steroids for mothers at risk of giving birth prematurely, while we did not find any study that assessed interventions that aimed to restrict the use of steroids. Two studies were conducted in hospital settings of mostly high‐income countries, while one study was conducted in low‐resource settings in six low‐and middle‐income countries. Two studies found that the interventions led to an increase in the use of steroids, while one study found no difference in the use of steroids. One large study in low‐resource settings found that among women who delivered preterm infants, more women in the intervention group (45%) received steroids compared to women the control group (10%) (low‐certainty evidence). However, in the group of women who did not deliver preterm infants more women in the intervention group (10%) compared to the control group (1%) received steroids although they did not need them (low‐certainty evidence).

Only the one large study that was conducted in low‐resource settings assessed important outcomes. The study found that perinatal death (death of the baby before birth or within the first seven days of life), stillbirth (death of the baby before birth), and neonatal death before 28 days (death of the baby during the first 28 days of life) probably occurs more often among all babies (not just those that are born prematurely) when the use of steroids is actively promoted compared to usual care (moderate‐certainty evidence). It also found that infection in the mother may be more common when strategies to increase the use of steroids are in place. However, there may be little or no difference between groups in the mothers' risk of dying (low‐certainty evidence).

What does this mean?

In low‐resource settings, a strategy of actively promoting the use of steroids in mothers at risk of giving birth prematurely could be harmful to infants and their mothers at population level. Policy makers need to carefully weigh the benefits against the potential risks when considering scaling up of this intervention in low‐resource settings. There is a need to do more research on the effectiveness of approaches to scale up the use of steroids for mothers at risk of premature delivery in low‐resource countries.